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Psychological Trauma Article

Psychological
Trauma – What Every Trauma Worker Should Know

Zoe
Lodrick MSc. BA Hons (1st). Dip (psych). Dip (couns). UKCP

Abstract

In this paper I outline the basis of psychological trauma.I surmise what happens to the human brain and
nervous system at the point of trauma, and during trauma recall (both choiceful
and intrusive).I discuss how, and why,
some people may be more susceptible to developing traumatic symptomatology, and
possible reasons for the repeat victimization experienced by so many victims/survivors
of interpersonal trauma.I suggest how
psychotherapists, and other trauma workers, might use this knowledge to support
the client to recover, and to sustain themselves in undertaking trauma work.

Introduction

A traumatic incident is one in which a person experiences, witnesses or,
in certain circumstances, hears about a (real or perceived) threat to the
physical and/or psychological integrity of self, or others, whereby the
person’s response involves great fear, horror and/or helplessness (APA, 2000;
Rothschild, 2000).Exposure of a child to
the sexualized behaviour of adults or older children, regardless of whether the
child responds with great fear, horror and/or helplessness, also constitutes a
traumatic incident, due to the developmentally inappropriate nature of the
sexualized behaviour(s) (APA, 2000), and the child’s inability to give informed
consent.

Traumatic experience, and traumatization, can be subdivided into:
primary trauma, secondary trauma, vicarious trauma and trans-generational
trauma.People susceptible to primary
trauma are present when the traumatic incident occurs; secondary trauma is a
possibility for people who witness the aftermath of a traumatic incident;
vicarious trauma is potentially a concern for people who hear about traumatic
incidents (psychotherapists for example); and trans-generational trauma is a
term sometimes used to describe the traumatic symptomatology displayed by the
descendants of trauma survivors.Following
exposure to traumatic stimuli some people become traumatized.I discuss the possible reasons for some
people being more susceptible to developing post-trauma symptomatology in this
paper.It is important to note that
although traumatization frequently occurs following a single traumatic incident
the condition is also an accumulative one.This is especially significant to anyone who works in an environment
where they are exposed to traumatic stimuli (primary, secondary and/or
vicarious) for example members of the emergency services, armed forces, medics
and those engaged in psychological therapies with traumatized people.

Arguably, what separates people who are traumatized from those who once
had something unpleasant happen to them, is a difficulty for the former with
past/present differentiation (Herman, 1992; van der Kolk, 1989 & 1996).For the traumatized individual some aspect of
the trauma is experienced as a here and now reality.In this paper I offer a framework for
understand why some people become stuck in an aspect of the trauma, and how
this knowledge might inform recovery.

Neurobiology of trauma – a basic outline

The human brain is immensely complex and I do not profess to be a
neurobiologist.I have, however, found
the neurobiological research to be invaluable in understanding how the human
animal behaves when threatened, and how these behaviours might be the key to understanding
traumatization and, subsequently, to recovery.

Humans are mammals, very highly advanced mammals, but mammals all the
same.The human brain has evolved to
incorporate, amongst other things, the capacity for: language, reasoning,
creativity, philosophy and self-awareness.The higher brain functioning enjoyed by humans sets us apart from other
mammals. Yet the human brain evolved to
possess advanced capabilities, and the higher levels rest upon more instinctive
and reflexive structures – figuratively and literally.

The human brain is hierarchically organized into three sections: the
lower, or reptilian, brain incorporates the brain stem and is primarily
associated with the unconscious regulation of internal homeostasis (van der
Kolk, 2003); the upper brain, or neo-cortex, is responsible for higher brain
functions (Siegel, 1999), analysis of the external world (van der Kolk, 2003), and
self-awareness and consciousness (Lanius et al., 2006); and the middle, or
limbic, brain which surrounds the reptilian brain, is found in all mammals and
is involved with learning, motivation, memory, emotional regulation and some
social behaviour (Cozolino, 2002; Lanius et al., 2006). Additionally, the brain consists of two
hemispheres: right and left.The two sides
of the brain, for the most part, work together yet specialize in differing
functions (Siegel, 1999).The left brain
is generally accepted to be closely identified with cortical functioning and
the right more densely connected with the limbic and reptilian brain (Cozolino,
2002).The left brain is concerned with what
Siegel refers to as the “three L’s – linear, logical, linguistic” (Siegel,
2003: 15); and the right brain is connected with the body, regulation of the
autonomic nervous system (ANS), nonverbal aspects of language and more
emotional functions (Cozolino, 2002; Siegel, 2003).

Significantly, in terms of trauma, the structures largely involved in responding
to threat are located in the lower and mid sections of the (predominantly)
right brain.This means when threatened
human beings respond, initially at least, instinctively and reflexively.

Most people will have had an experience of responding to something
perceived as threatening before they
were aware of the threat.For example, a
man walking through the Australian bush might find himself immobilized moments
before his higher brain functions process the snake-like-stick on the floor.He responds instinctively to the snake-like
object with behaviour most likely to ensure survival.It is some moments later that his neo-cortex
processes the finer detail and assesses the stick to be less threatening than
originally perceived.The reason for the
brain processing information in this way is simple: it prioritizes
survival.The capacity for philosophical
theorising is worth little to a man who just stood on a venomous snake!

The human
brain is wired up in such a way that survival is given precedence. The
amygdala’s role in survival is paramount.Every piece of sensory input that enters our brain is routed via the
thalamus (in the reptilian brain) and then to the amygdala (in the limbic
brain) (Cozolino, 2002; van der Kolk, 1996a). The neural pathway from the thalamus to the
amygdala is fast- and necessarily so (LeDoux, 1996).The amygdala filters the information
searching out threat.If any threat is
recognised, whether real or perceived, the hypothalamus is immediately
stimulated to respond.It does so by triggering
the release of stress hormones to prepare the body to defend itself (Cozolino,
2002), and by alerting the sympathetic branch of the ANS to become highly
aroused in readiness to meet the threat (Ogden & Minton, 2000; Rothschild,
2000; Siegel, 1999).

A split second after the thalamus sends sensory information to the
amygdala it begins the much slower neural process of sending the same
information to the hippocampal and cortical circuits for further evaluation
(LeDoux, 1996).The findings of the hippocampus
and cortex are then relayed back to the amygdala.In the previous example, of the man and the
stick that resembles a snake, the amygdala will be encouraged to calm (motionless
sticks do not usually pose a threat to physical or psychological integrity).

Terror overwhelms higher brain functioning (Siegel, 2003), as “the focus
on immediate survival supersedes all medium- and long-term goals” (Cozolino,
2002: 252).Possible reasons for this
include the necessity of the brain to surrender oxygen to the body, and the
high levels of stress hormones such as cortisol (Ogden et al., 2006), and
norepinephrine (Cozolino, 2002) affecting hippocampal functioning (van der
Kolk, 1996a).

When the structures of the brain lose, or lack, integration,
dissociation may occur (Cozolino, 2002).“In trauma, dissociation seems to be the favoured means of enabling a
person to endure experiences that are at the moment beyond endurance” (Levine,
1997: 138).While dissociation is a
creative way of surviving in the moment, it bodes ill for future psychological
and physical wellbeing (van der Hart et al., 2006).

The five Fs

The human system broadly responds in one (or more) of five predictable
ways when threatened. ‘Fight, flight and
freeze’ are well documented responses to threat (Levine, 1997); to these I add ‘friend’
and ‘flop’ (Ogden and Minton, 2000; Porges, 1995 & 2004).The five Fs, are instigated by the amygdala
upon detection of threat. The amygdala
responds to the threat in the way it perceives will most likely lead to
survival.

Friend is the
earliest defensive strategy available to us. At birth the human infant’s amygdala is
operational (Cozolino, 2002), and they utilize their cry in order to bring a
caregiver to them.The non-mobile baby
has to rely upon calling a protector to its aid, in the same way that the
terrified adult screams in the hope that rescue will come.Once mobile the child may move toward another
for protection, and with language comes the potential to negotiate, plead or
bribe ones way out of danger.Throughout
life when fearful most humans will activate their social engagement system
(Porges, 1995).

The social engagement system, or friend
response to threat, is evident in the child who smiles or even laughs when
being chastised.To smile when fearful
is likely to be an unconscious attempt to engage socially with the person
causing the fear.

Fight, as a
survival strategy, is fairly self explanatory.The threatened individual may respond with overt aggression or more
subtle ‘fight behaviours’, for example saying “no”.

Flight is any
means the individual uses to put space between themselves and the threat.It may involve sprinting away from the
perceived danger, but is more likely exhibited as backing away or, particularly
in children, as hiding.

When the amygdala deems that friend, fight or flight are not likely to
be successful it will elicit a freeze
response.Levine points out that
immobility has several advantages to mammals when threatened by a predator, namely:
that the predator has less chance of detecting immobile prey; that many
predatory animals will not eat meat that they consider to be dead; and that if
the predator does kill, the freeze mechanism provides a natural analgesic
(Levine, 1997).Between mammals of the
same species the freeze response indicates submission, with the victorious
animal recognising their dominance and leaving the subordinate animal
alone.In the majority of inter-personal
threats between humans however, the advent of one party freezing is often
either ignored or taken as consent to the assault (whether verbal, physical or
sexual).

Flop occurs if,
and when, the freeze mechanism fails.The moment the threat increases, despite freeze having intended to put
an end to the situation, the amygdala will trigger the ANS to swing from
predominantly sympathetic activation to parasympathetic activation (Rothschild,
2000).The body will shift from a
position of catatonic musculature tension (as is observed in ‘freeze’) to a
‘floppy’ state, whereby muscle tension is lost and both body and mind become
malleable (hippocampal and cortical functioning will very likely be severely
impaired at this point).The survival
purpose of the flop state is evident: if ‘impact’ is going to occur the
likelihood of surviving it will be increased if the body yields, and
psychologically, in the short-term at least, the situation will be more
bearable if the higher brain functions are ‘offline’.People who have elicited flop as a survival
mechanism are very submissive and will make little or no outward protest
concerning what is happening to them.They will bend to the will of the person perceived as threatening in an
attempt to stay alive.

Which ‘f’ and why?

It is my contention that the survival strategy adopted in any given
situation will depend on a number of factors, namely:

1.What is
most likely to ensure survival (and also maintain vital attachments)?

2.What
worked in the past?

3.What was
unsuccessful in the past?

Different survival strategies are ideally suited to certain threatening
situations; for example, flight would be well employed upon hearing a fire
alarm, yet to flee from a hungry tiger is inadvisable.The reflexive response of the amygdala is
informed by the genetically encoded information, shared by all humans,
regarding the nature of certain threats (Levine, 1997), and the individual’s
subjective experience that has resulted in the pairing of a fear response with
certain stimuli (Cozolino, 2002).

Because the purpose of the five Fs is survival, success will be gauged
in survival terms; “success doesn’t mean winning, it means surviving, and it
doesn’t really matter how you get there.The object is to stay alive until the danger is past.” (Levine,
1997:96). Successfully used strategies
will be reinforced and strategies employed but unsuccessful, will be less
likely to be used in future.

A person who is successful in actively defending against a threat (i.e.
utilizes friend, fight or flight) is less likely to become traumatized than
someone who uses passive defences (freeze or flop) (Herman, 1992; van der Kolk
1996).If active defences are weakened,
by lack of success, and/or passive defences strengthened through successful
utilization, the likelihood of a person becoming traumatized and/or a repeat
victim of trauma are increased.I will
illustrate this point with an example:

Jenny was sexually abused throughout her childhood by her father, her uncles
and a number of other men.Some years
later Jenny was standing at the side of the road waiting for her friend (who
was 10ft away buying greengrocery from a market stall).A car pulled up alongside Jenny and the man
inside (one of the men who had abused Jenny as a child) opened the back door
and said, “Get in”.Jenny got into the
car and the man reached back and closed the door.He then drove her to a flat, took her inside,
and raped her.

I met Jenny a few weeks after that incident.In our initial psychotherapy sessions she was
furious with herself for getting in the car, she ruminated over questions such
as “why didn’t I run, or shout, or say ‘no’?” and berated herself with “I’m
such an idiot, when will I learn?” Of
course, when judging herself so harshly, Jenny had the benefit of the hippocampal
and cortical functioning that had been unavailable to her when she chose to
obey the man’s command.Jenny had
responded in the way her amygdala had been ‘programmed’ to respond.The traumatic experiences of her childhood
would, undoubtedly, have resulted in a coupling of this man’s presence with an amygdala-mediated
flop response; a response that would have been reinforced by its repeated
‘success’ throughout her childhood (in much the same way that our genetic
heritage favours and reinforces a freeze reaction to the presence of a snake).The fact that many years had passed since she
had last seen the man was of no consequence, the neural networks that mediate
reflexive fear responses are “context free, meaning that [they] contain no
information about the location, time, or perspective from which the learning
took place” (Cozolino, 2002:246).Hippocampal input is required to ascribe a sense of time (LeDoux, 1996)
– to both experience and memory – and with the level of fear Jenny was experiencing
hippocampal processes would be unlikely to function.As a result Jenny would not have been able to
support herself with the reality that many years had passed since her last
encounter with this man, nor with the fact that she is now a grown woman with
other options available to her.

Sadly, the consequences of the amygdala’s learnt response can be grave
for the most vulnerable people in our society. Fear results in a lowering of, the
predominantly left brain, cortical and hippocampal functioning (van der Kolk,
1996a) and the individual becomes “dependent upon the neural circuits that
evolved to provide adaptive defences for more primitive vertebrates” (Porges, 2004:24),
the upshot of the fast reflexive response to perceived threat, is that
longer-term wellbeing is too frequently compromised for short-term survival
(Siegel, 1999).

Because the amygdala is densely linked into the neurological processing
of both fear and attachment (Cozolino, 2002), survival and maintaining
attachments are inextricably intertwined (Porges, 2004).Bessel van der Kolk maintains that terrified people
do not move away from danger toward safety, rather that people fleeing
threatening situations move toward ‘home’, the familiar, or their attachment
object (van der Kolk 2004).This has
significant implications for individuals who perceive threat in their ‘home’
and/or perpetrated by someone they love.When confronted with a significant threat from someone depended upon,
most people respond in a way that best ensures continued attachment to that
person.Meaning, that even when escape
is objectively possible, the likelihood of the amygdala eliciting a fight or
flight response is low.This, coupled
with the amygdala’s tendency to replicate previously ‘successful’ survival
strategies, results in many people being vulnerable to repeated (verbal,
physical and/or sexual) assaults by their ‘loved ones’.

If you have ever found yourself wondering why people ‘go back for more’,
consider a time you had your heart broken by someone ending a relationship with
you.I imagine there were family and
friends willing to support and comfort you – yet I also imagine the person you
wanted was the one who had caused the pain in the first place.Logical?No.But logic isn’t the
amygdala’s strong point –survival and attachment are.

The extent to which we use attachment as a survival strategy can be
observed in the phenomena referred to as Stockholm syndrome (van der Kolk,
1996).The term Stockholm syndrome was
adopted after a 1973 bank siege in Sweden resulted in the hostages ‘protecting’
the criminals who had taken them captive, resisting rescue and ultimately refusing
to give evidence against the hostage takers. Stockholm syndrome or trauma bonds result in
the victim experiencing positive feelings toward their victimizer, negative
feelings toward potential rescuers, and an inability to engage in behaviours
that will assist detachment or release (Carnes, 1997).It develops after just four days of captivity
within which the victim fears for their life, is isolated from other people and
is subject to cruelty interspersed with small kindnesses.Hostage situations are relatively rare yet
the described conditions are frighteningly common in domestic situations
(Herman, 1992).

Why are some people more susceptible to traumatization?

Experience
of trauma is part of the human condition (van der Kolk & McFarlane, 1996),
and in a world where all creatures are located somewhere in the food chain,
nature has evolved mechanisms to contend with the terror inherent in existence
(Levine, 1997). Yet, despite these
mechanisms, some people develop traumatic symptomatology following a traumatic
incident. Symptoms of psychological
traumatization include: the persistent re-experiencing of the traumatic event
whilst (unsuccessfully) trying to avoid stimuli associated with it (APA, 2000);
an inability to modulate ANS arousal (Ogden et al, 2006; Rothschild, 2000;
Siegel, 1999); somatic symptoms (Briere & Scott, 2006); alterations in
sense of self and identity (Herman, 1992); and compulsive re-exposure to, or re-enactment
of, the trauma (Herman, 1992; van der Kolk & McFarlane, 1996).

Traumatic symptomatology has, at its foundation, a lack of sufficient
neural integration (Cozolino, 2002; van der Kolk, 2003).The debilitating symptoms suffered by so many
traumatized individuals are manifestations of survival strategies (the five Fs),
at a time when survival strategies are objectively not needed.The person’s nervous system continues to
respond as if they are in danger days, weeks, months even decades after the
threat is passed.

There are a number of possible reasons for some people being more
susceptible to developing traumatic symptoms.Notably, a person is more likely to become traumatized if:

1.they are
very young (Schore, 2003) or very old when the incident occurs (Briere &
Scott, 2006);

“Traumatized people lead traumatic and traumatizing lives” (van der Kolk
& McFarlane, 1996:11).Notions of
repetition are central to most models of psychotherapy (Moursund & Erskine,
2004; O’Brien & Houston, 2000) and for traumatized individuals their day to
day existence is plagued with intrusive replays of the original trauma.van der Kolk (1989) argues that contrary to
Freud’s belief that repetition is an attempt to gain mastery, traumatized
individuals rarely do so and, the cycling of behaviours, cognitions and affect
associated with the trauma merely cause more suffering to the victim and the
people around them. Trauma re-enactments
are common and take the forms of: revictimization, self-injurious and self-harming
behaviours and externalizing the trauma by victimizing others (van der Kolk
& McFarlane, 1996).

My close colleague, Kim Hosier, illustrates the concept of trauma
re-enactment with an ice-skating metaphor: If a skater makes a circuit of the ice, a
shallow groove will be left.If the
skater then repeats the circuit the groove will deepen.Add a third, fourth and fifth circuit and the
groove becomes significant.Soon the
skater will find taking a different route across the ice difficult, and to do
so will take concentration and effort.Should the skater manage to alter her route there is high probability
that she will slip back into the groove created by the original circuit.Kim contends that psychotherapy with
traumatized people is all about helping them to make different patterns in the
ice.

In neurobiological terms the ‘grooves in the ice’ are neural networks
created by the firing, and wiring, together of neurons.This is the basis of all learning (Cozolino,
2002).Without the capacity of the brain
to create readily, and unconsciously, activated neural pathways it would be
necessary to relearn how to walk every time.Indeed, the neural pathways that govern walking were organized at a time
when hippocampal and cortical functioning were under-developed (similar neurological
conditions to those elicited by trauma) yet walking is something we remember
how to do, even if we do not recall how we learnt to do it (Cozolino,
2002).The habitual patters of behaviour
that result in the cycling of trauma are encoded similarly.

For traumatized individuals memories of trauma are determined differently
to non-traumatic memories.The
hippocampus and cortical regions of the brain are central to the mediation and
storage of explicit memory, which is
autobiographical, organized by language, adaptable, contextualized and subject
to conscious organization and recall (Cozolino, 2002; Siegel, 1999).Because trauma disrupts hippocampal and
cortical functioning their vital role in mediating explicit memory is also
disrupted.As a result traumatic
experiences are more likely to be stored predominantly as implicit memory (Cozolino, 2002; LeDoux, 1996; Siegel, 1999), which
is emotional, sensory, less adaptable, context-free, and concerned with unconscious
procedural learning (Cozolino, 2002; Rothschild, 2000).

Let us again consider Jenny’s experience outlined earlier in this
article.When told to get into the car
she did, and only afterwards did she berate herself for not having elicited an active
defence: “why didn’t I run, or shout, or say ‘no’?”(shouting would have constituted a ‘friend
response’, saying “no” a ‘fight response’ and running a ‘flight response’).Remember, when threatened the human system
responds reflexively with amygdala-mediated defences, and because the amygdala
is densely linked to implicit memory (including implicit data about previous
traumas) it will be hyper-sensitive to any trigger related to previous
trauma.As outlined earlier the amygdala
has a tendency to generalize (e.g. snake-like objects elicit the same response
as snakes) and coupled with the context free form of implicit memory this is a
cocktail for trauma replay.

For traumatized individuals to break the trauma cycle they must be
supported to assign the original trauma to the past, where it belongs.

Principles of recovery from trauma

I have thus far outlined current neurobiological thinking concerning the
human response to threat.A basic
understanding of the processes involved is essential to any trauma worker.Because implicit memory is context free whenever
it is triggered the traumatized client will re-experience, to a greater or
lesser extent, the amygdala-mediated survival response and the ANS (autonomic
nervous system) activation, experienced at the time of the incident.Memory can be triggered unconsciously within
therapy (stimuli that cause intrusive non-choiceful recall and/or replay of the
incident) and also consciously (when we ask, or encourage, our clients to talk
about their traumatic experiences).Whether consciously or unconsciously elicited, unless the client is
actively supported toward regulating their out-of-context fear response, the
likelihood is that recall will simply add another groove to their trauma
script.

In this section it is not my intention to present a model for working
with trauma, there are many excellent models available (Herman, 1992; Ogden el
al, 2006; Rothschild, 2000; Shapiro, 1995), instead I intend to outline some
basic principles that will be readily integrated into most therapeutic
paradigms.I will briefly address each
of the principles:

Prepare
well: A solid working alliance is essential to trauma work.The client needs to be well enough resourced
(Shapiro, 1995), both internally and externally, before you can begin to
process the trauma.

Support
the client to remain within their window of tolerance (Siegel, 1999).“Each of us has a ‘window of tolerance’ in
which various intensities of emotional arousal can be processed without
disrupting the functioning of the system” (Siegel, 1999:253).Emotional arousal beyond tolerable levels
results in either hyper-arousal (which roughly correlates with fight and
flight) or hypo-arousal (akin to freeze and flop) of the ANS (Ogden &
Minton, 2000; Siegel, 1999).

The client’s experience of hyper or hypo arousal, during a psychotherapy
session, is likely to indicate a replay of the original trauma, and a displaced
(in time) fight, flight, freeze or flop response.It is important to support the client (and
yourself) in countering the effects of hyper and hypo arousal and thus
remaining in, or returning to, the window of tolerance.Only when the client is firmly within their
window of tolerance will they possess the integrative brain functioning
necessary for recovery.My clinical
experience suggests that a combination of the following techniques work well in
helping the person to remain within their window of tolerance and also in
expanding the breadth of the window:

1.Monitor
and manage respiration (note: breathing is the only function of the ANS that
most people can bring under conscious control).To regulate hyper-arousal (fight/flight) encourage the client to ‘blow
out’ through their mouth; for hypo-arousal (freeze/flop) encourage the client
to take deep in breaths.

2.Draw
attention to the current, non-threatening, reality.You can do this in a multitude of ways.For example you might state: “right here,
right now nothing bad is happening”, or “you are remembering something that
already happened, it is not happening now – it is a memory”; or you might ask
the client to look around the room and name the things that are familiar to
them.

3.Ensure
that cortical and hippocampal functioning remain available to the client.If functioning appears to be significantly impaired
ask the client simple cortical questions like: “how many fingers am I holding
up”, “what colour is that lamp”, or “how many panes can you count in that
window”.Keep the questions simple and
observable.

4.Ensure
that neither you nor your client becomes immobilized during sessions.If you discover either, or both, of you are
frozen immediately act to rectify the situation.Start with small movements, for example
encourage the client to wiggle their toes (obviously it is important to explain
why you are doing this).

5.Ground, the
client, through their body, to the here and now (Rothschild, 2000).There are many ways of doing this and it is
especially useful for clients who experience periods of dissociation,
depersonalization and/or derealization during sessions.You might, for example, bring the clients
attention to the physical sensation of the ground under their feet and perhaps
suggest that the client pushes into the ground (as if to push their chair over
backwards, but without actually doing so).

6.Utilize
what you know of your client’s good experiences, relationships and ‘safe place’
(Shapiro, 1995), to slow the process down (Rothschild, 2000).For example, if you know your client feels
safe in his garden encourage him to imagine himself there and to describe what
he sees, hears, smells, tastes and feels; or if your client has a beloved pet
encourage them to conjure up an image/sense of that pet as if they are with
them now.

At all
times aim to expand the client’s window of tolerance and their neurological
integration.Putting
narrative to traumatic experience increases integration among neural networks
(van der Kolk, 1996a) however, it is imperative that you only do this whilst
the client is contained within their window of tolerance. It is also important to recognise that the ‘story’ is therapeutically less
important than the present moment experience.Bring your attention, and that of the client, to the moment by
moment experiencing of cognitions, emotions, five-sense perception, movement,
inner body sensation and the shifting relationship between them (Ogden et al.,
2006).

Work
toward symptom reduction, be patient and encourage the client to be patient
too.The implicit memories being
addressed, whether directly or indirectly, are often as hard wired into the
brain as the way we walk.If you have
limited time to work focus on managing the symptoms and increasing the client’s
resources.

Be
predictable.Client’s
need to be able to rely on your ‘sameness’ – trauma is about dysregulation and
you need to model regulation.Traumatized
clients will, frequently, be hyper-vigilant and will pick up any changes in you
and their environment.Often their
senses are spookily astute, yet they will tend to interpret their findings
within their traumatic experience.For
example a woman who was physically abused by her sadistic mother might
interpret your tiredness (induced by antihistamine) as being an indicator that
she has angered you and that she is in danger.

Know that “recovery can only take
place in the context of relationships....In her renewed connections with
other people, the survivor re-creates the psychological faculties that were
damaged or deformed by the traumatic experience” (Herman, 1992:133).And,
above all be vigilant for the ‘pull’ to re-create
the client’s trauma!

Sustenance for the trauma worker

Fear is readily transferred from being to being, to increase the
likelihood of the herd, pack or the clan’s survival (Levine, 1997).This is very useful when genuine danger is
present, however for workers who spend hours in close proximity with
traumatized individuals the affect on their ANS can be profound.For that reason it is vital that anyone who
works with trauma, not only supports their client to regulate their nervous system,
but ensures they attend to their own – both within, and after, sessions.

The psychotherapist needs to be attentive to their own ANS activation to
ensure that they remain within their window of tolerance.Indeed, the therapist who becomes adept at
paying mindful attention to their own ANS and bodily states will have a useful
barometer for what might be occurring within their client.If a therapist recognises a significant swing
toward either hyper or hypo activation they must first attend to their own need
for regulation before concerning themselves with their client.This might seem harsh to the empathically
attuned psychotherapist but a dysregulated therapist is of little use to his or
her client(s).

Similarly, I strongly recommend that therapists actively choose not to
imagine the traumatic scene as the client tells their story (this is not easy
for clinicians and that is why I suggest an active decision not to ‘go there’).Instead attune to the client’s current ANS activation
and provide vital support to the client in remaining sufficiently grounded in
the here and now.

In conversations with colleagues I have recognised that it seems to be a
common experience that, despite good diary management, clinicians will
sometimes find that all of their most traumatized clients are coming on the
same day.Ensure you have time between
sessions to attend to your needs and, ideally, have colleagues available to
support you in noticing what you are missing.

It almost goes without saying that good, regular, supervision is
imperative for anyone undertaking trauma work.Ideally your supervisor should be familiar with the affects of vicarious
traumatization and burn out, and should be vigilant at recognising when you are
‘stepping into’ some form of trauma replay.A good solid supervisory alliance is essential if the therapist is to
feel safe enough to allow the depth of supervision necessary for this type of
work.The mechanisms of friend, fight, flight, freeze and flop
will almost certainly be evident in the supervisory process, as will traumatic
re-enactment, and the reactions so often experienced by trauma survivors
themselves will, from time to time, be elicited; notable among them are:
denial, withdrawal, disgust, admiration, voyeurism and blame.

Conclusion

Trauma has a dis-integrative impact on brain functioning.The dissociation between neural networks is,
initially at least, intended to optimize the individual’s chance of
survival.For some people the
dissociation and lack of integration persist and a wide array of traumatic
symptomatology are exhibited.Psychotherapy with traumatized individuals should ideally aim to
increase neural integration, top to bottom (Ogden et al., 2006), and left to
right (Shapiro, 1995).Neural
integration is increased when the client is supported to remain within their
window of tolerance and, previously dissociated, cognitions, affect and body
sensations are reconnected.With neural
integration comes better regulation of the ANS and associated symptom
reduction. Traumatic experiences can then be assigned to the past, where they
belong, and the once traumatized individual is released from the cyclic nature
of trauma.